Tendons are strong cords of fibrous tissue that attach muscles to bones. The patellar
tendon works with the muscles in the front of your thigh to straighten your leg.

Small tears of the tendon can make it difficult to walk and participate in other daily
activities. A large tear of the patellar tendon is a disabling injury. It usually
requires surgery and physical therapy to regain full knee function.

Anatomy

The patellar tendon attaches the bottom of the kneecap (patella) to the top of the
shinbone (tibia). It is actually a ligament that connects to two different bones,
the patella and the tibia.

The patella is attached to the quadriceps muscles by the quadriceps tendon. Working
together, the quadriceps muscles, quadriceps tendon and patellar tendon straighten
the knee.

Partial tears. Many tears do not completely disrupt the soft tissue. This is similar to a rope stretched
so far that some of the fibers are frayed, but the rope is still in one piece.

Complete tears. A complete tear will disrupt the soft tissue into two pieces.

When the patellar tendon is completely torn, the tendon is separated from the kneecap.
Without this attachment, you cannot straighten your knee.

The patellar tendon often tears at the place where it attaches to the kneecap, and
a piece of bone can break off along with the tendon. When a tear is caused by a medical
condition — like tendinitis — the tear usually occurs in the middle of the tendon.

Injury

Falls. Direct impact to the front of the knee from a fall or other blow is a common cause
of tears. Cuts are often associated with this type of injury.

Jumping. The patellar tendon usually tears when the knee is bent and the foot planted, like
when landing from a jump or jumping up.

Tendon Weakness

A weakened patellar tendon is more likely to tear. Several things can lead to tendon
weakness.

Patellar tendinitis. Inflammation of the patellar tendon, called patellar tendinitis, weakens the tendon.
It may also cause small tears.

Patellar tendinitis is most common in people who participate in activities that require
running or jumping. While it is more common in runners, it is sometimes referred to
as "jumper's knee."

Corticosteroid injections to treat patellar tendinitis have been linked to increased
tendon weakness and increased likelihood of tendon rupture. These injections are typically
avoided in or around the patellar tendon.

Chronic disease. Weakened tendons can also be caused by diseases that disrupt blood supply. Chronic
diseases which may weaken the tendon include:

Chronic renal failure

Hyper betalipoproteinemia

Rheumatoid arthritis

Systemic lupus erythmatosus (SLE)

Diabetes mellitus

Infection

Metabolic disease

Steroid use. Using medications like corticosteroids and anabolic steroids has been linked to increased
muscle and tendon weakness.

Surgery

Previous surgery around the tendon, such as a total knee replacement or anterior cruciate
ligament reconstruction, might put you at greater risk for a tear.

Medical History and Physical Examination

Your doctor will discuss your general health and the symptoms you are experiencing.
He or she will also ask you about your medical history. Questions you might be asked
include:

Have you had a previous injury to the front of your knee?

Do you have patellar tendinitis?

Do you have any medical conditions that might predispose you to a knee or a patellar
tendon injury?

Have you had surgery to your knee, such as a total knee replacement or an anterior
cruciate ligament reconstruction?

After discussing your symptoms and medical history, your doctor will conduct a thorough
examination of your knee. To determine the exact cause of your symptoms, your doctor
will test how well you can extend, or straighten, your knee. While this part of the
examination can be painful, it is important to identify a patellar tendon tear.

Doctors use the knee extension test to help diagnose a quadriceps tendon tear.

Imaging Tests

To confirm the diagnosis, your doctor may order some imaging tests, such as an x-ray
or magnetic resonance imaging (MRI) scan.

X-rays. The kneecap moves out of place when the patellar tendon tears. This is often very
obvious on a "sideways" x-ray view of the knee. Complete tears can often be identified
with these x-rays alone.

MRI. This scan creates better images of soft tissues like the patellar tendon. The MRI
can show the amount of tendon torn and the location of the tear. Sometimes, an MRI
is required to rule out a different injury that has similar symptoms.

(Left) This x-ray taken from the side shows the normal location of the kneecap. (Right) The kneecap has moved out of place due to a torn patellar tendon.

Nonsurgical Treatment

Immobilization. Your doctor may recommend you wear a knee immobilizer or brace. This will keep your
knee straight to help it heal. You will most likely need crutches to help you avoid
putting all of your weight on your leg. You can expect to be in a knee immobilizer
or brace for 3 to 6 weeks.

Physical therapy. Once the initial pain and swelling has settled down, physical therapy can begin.
Specific exercises can restore strength and range of motion.

While you are wearing the brace, your doctor may recommend exercises to strengthen
your quadriceps muscles. Straight-leg raises are often prescribed. As time goes on,
your doctor or therapist will unlock your brace. This will allow you to move more
freely with a greater range of motion. You will be prescribed more strengthening exercises
as you heal.

Surgical Treatment

Most people require surgery to regain knee function. Surgical repair reattaches the
torn tendon to the kneecap.

People who require surgery do better if the repair is performed soon after the injury.
Early repair may prevent the tendon from scarring and tightening into a shortened
position.

Hospital stay. Although tendon repairs are sometimes done on an outpatient basis, most people do
stay in the hospital at least one night after this operation. Whether or not you will
need to stay overnight will depend on your medical needs.

The surgery may be performed with regional (spinal) anesthetic which numbs your lower
body, or with a general anesthetic that will put you to sleep.

Procedure. To reattach the tendon, sutures are placed in the tendon and then threaded through
drill holes in the kneecap. The sutures are tied at the top of the kneecap. Your surgeon
will carefully tie the sutures to get the correct tension in the tendon. This will
also make sure the position of the kneecap closely matches that of your uninjured
kneecap.

(Left) Sutures are passed through small holes that have been drilled into the kneecap.
(Right) The sutures are tied at the top of the kneecap.

New Technique. A recent development in patellar tendon repair is the use of suture anchors. Surgeons
attach the tendon to the bone using small metal implants (called suture anchors).
Using these anchors means that drill holes in the kneecap are not necessary. This
is a new technique, so data is still being collected on its effectiveness. Most orthopaedic
research on patellar tendon repair involves the direct suture repair with the drill
holes in the kneecap.

Considerations. To provide extra protection to the repair, some surgeons use a wire, sutures, or
cables to help hold the kneecap in position while the tendon heals. If your surgeon
does this, the wires or cables may need to be removed during a later, scheduled operation.

Your surgeon will discuss your need for this extra protection before your operation.
Sometimes, surgeons make this decision for additional protection during surgery. It
is then that they see the tendon shows more damage than expected, or the tear is more
extensive.

If your tendon has shortened too much before surgery, it will be hard to re-attach
it to your kneecap. Your surgeon may need to add tissue graft to lengthen the tendon.
This sometimes involves using donated tissue (allograft).

Tendons often shorten if more than a month has passed since your injury. Severe damage
from the injury or underlying disease can also make the tendon too short. Your surgeon
will discuss this additional procedure with you prior to surgery.

Complications. The most common complications of patellar tendon repair include weakness and loss
of motion. Re-tears sometimes occur, and the repaired tendon can detach from the kneecap.
In addition, the position of your kneecap may be different after the procedure.

As with any surgery, the other possible complications include infection, wound breakdown,
a blood clot, or anesthesia complications.

Rehabilitation. After surgery you will require some type of pain management, including ice and medications.
About 2 weeks after surgery, your skin sutures or staples will be removed in the surgeon's
office.

Most likely, your repair will be protected with a knee immobilizer or a long leg cast.
You may be allowed to put your weight on your leg with the use of a brace and crutches
(or a walker). To start, your surgeon may recommend "toe touch" weight bearing. This
is when you lightly touch your toe to the floor, putting down just the weight of your
leg. By 2 to 4 weeks, your leg can usually bear about 50% of your body weight. After
4 to 6 weeks, your leg should be able to handle your full body weight.

Over time, your doctor or therapist will unlock your brace. This will allow you to
move more freely with a greater range of motion. Strengthening exercises will be added
to your rehabilitation plan.

In some cases, an "immediate motion" protocol (treatment plan) is prescribed. This
is a more aggressive approach and not appropriate for all patients. Most surgeons
protect motion early on after surgery.

The exact timeline for physical therapy and the type of exercises prescribed will
be individualized to you. Your rehabilitation plan will be based on the type of tear
you have, your surgical repair, your medical condition, and your needs.

Complete recovery takes about 6 months. Many patients have reported that they required
12 months before they reached all their goals.

Most people are able to return to their previous occupations and activities after
recovering from a patellar tendon tear. Many people report stiffness in the affected
leg. Most regain nearly equal motion compared to the uninjured leg.

If you are an athlete, your surgeon will most likely want to test your leg strength
before giving a go-ahead to return to sports. Your surgeon will compare your leg strength
using some functional knee testing (like hopping). The goal is that your strength
be at least 85-90% of your uninjured side. In addition to leg strength, your surgeon
will assess your leg's endurance, your balance, and if you are having any swelling.

Your return to competitive status will be addressed very carefully with you by your
surgeon.

AAOS does not endorse any treatments, procedures, products, or physicians referenced
herein. This information is provided as an educational service and is not intended
to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance
should consult his or her orthopaedic surgeon, or locate one in your area through
the AAOS "Find an Orthopaedist" program on this website.